END HEP C SF. Strategic Plan Report prepared by

Transcription

1 END HEP C SF Strategic Plan Report prepared by

2 END HEP C SF Strategic Plan

3 Eliminating Hepatitis C in San Francisco: Why Now? San Francisco is profoundly impacted by the hepatitis C virus (HCV), a chronic liver disease easily transmitted to others through blood-to-blood contact. HCV is a significant driver of morbidity, liver cancer, and death. The availability of highly effective HCV treatment that is taken through an oral pill with few side effects gives us the remarkable ability to cure HCV in nearly all infected patients. We now have the tools to greatly reduce HCV-related morbidity and mortality, to break the cycle of forward transmission through treatment as prevention, and to ultimately eliminate HCV in San Francisco. To realize the potential of modern HCV therapy, in 2016 the San Francisco Department of Public Health (SFDPH), University of California, San Francisco (UCSF), and other community partners came together to establish the End Hep C SF initiative, a multi-sector independent consortium operating under the principles of collective impact. Like many communicable diseases, HCV disproportionately impacts marginalized populations, specifically people who inject drugs, people who are homeless or marginally housed, people of color (most notably African Americans), and people living with HIV. San Francisco has a long history of implementing cutting-edge, evidence-based interventions such as syringe access, opiate replacement therapy, health coverage for uninsured individuals, and overdose prevention services. 2 End Hep C SF Strategic Plan

4 WHY DOES IT MATTER? For many people living with HCV, the concern about the negative impact of HCV on their health can be overshadowed by fear of stigma and discrimination. People living with HCV are often stigmatized, largely because of fears of contagion or assumptions about injection drug use as the cause of HCV infection. People who are stigmatized are devalued in society, and this has far-reaching impacts on their social interactions and health. Experiencing or fearing stigma has been linked to physical illness, poor mental health, increased substance use, poverty, and reduced access to housing, education, and employment. 2 Fear of stigma can impact a person s willingness to see a healthcare provider for treatment that could lead to a cure for their HCV; it can also prevent them from seeking support from friends or family to help them cope with their infection. For these reasons, it is imperative to eliminate HCV in San Francisco - not only with a focus on the biomedical prevention and cure of the disease, but by pairing those efforts with education campaigns to reduce stigma, and promoting self-respect and culturally competent, sensitive care from providers. While some people who are infected with HCV are able to clear the virus on their own without treatment, most (75-85%) will develop chronic infection, and 2 in 3 people will develop chronic liver disease. Chronic liver disease often progresses slowly over a period of decades, frequently without the person infected or their medical provider knowing, unless they test for HCV. Even people who don t develop significant liver disease may experience symptoms of their HCV infection, including fatigue, loss of appetite, and joint pain. After successful treatment of HCV, people who have advanced fibrosis may have substantial improvement in their liver scarring but still require regular monitoring for hepatocellular carcinoma (HCC), a liver cancer that can develop in people with chronic liver disease. While deaths from other notifiable infectious diseases have steadily declined over the past decade, deaths from HCV have continued to rise, and the HCV-related death toll now exceeds all other nationally notifiable infectious conditions, combined (see figure below) Other nationally notifiable infectious conditions* WHAT DOES ELIMINATION REALLY MEAN? Numbers of deaths Hepatitis C Elimination is not the same as eradication. It is not realistic to believe that San Francisco will become a city without a single case of HCV infection at least not for a long time. People constantly move in and out of our city, leaving or arriving for work or play on a regular basis. There are multiple definitions of disease elimination, but within End Hep C SF we define elimination of HCV as a state where HCV no longer poses a public health threat in San Francisco, and where those few who become infected with HCV quickly learn this has occurred and access curative treatment without delay, preventing the forward spread of disease. 4 End Hep C SF Strategic Plan

5 San Francisco is the ideal place to lead the way toward HCV elimination in the U.S., given our demonstrated ability to address critical issues impacting the health of San Franciscans head-on with innovative, evidence-based strategies. San Francisco is not the only U.S. jurisdiction exploring HCV elimination. In fact, this is a topic of particular concern to the Division of Viral Hepatitis at the CDC and the Office of Minority Health in the Department of Health and Human Services (HHS). Both offices sought guidance from the National Academies of Sciences, Engineering, and Medicine on the feasibility of eliminating HCV from the United States, ultimately leading to a report in 2016 that found control and elimination of HCV to be feasible but extremely difficult nationally. 3 The phase two report, to be published in 2017, will outline a strategy for meeting the elimination goals discussed in this phase one report. Moving beyond our borders, HCV is a global issue. In 2015, the 2030 Agenda for Sustainable Development was adopted by the General Assembly of the United Nations, with Sustainable Development Goal (SDG) 3.3 committing the UN to combating viral hepatitis. 4 In 2014, the World Health Assembly (the forum through which the World Health Organization is governed by its 194 member states) requested the World Health Organization (WHO) examine the feasibility of eliminating HCV. WHO modelled options and found that if the viral hepatitis response worldwide included comprehensive, high quality screening of blood donations, a significant increase in distribution of sterile syringe/needle sets for people who inject drugs (PWID), diagnosis of HCV in 90% of people living with the disease, and treatment of at least 80% of those eligible for treatment, then by 2030 we would see a 90% reduction in new chronic HCV infections and a 65% reduction in HCV-related deaths worldwide, compared with a scenario in which interventions would continue at the current level. 5 Indeed, one of the biggest barriers to HCV elimination has always been access to treatment. However, changes in Medi-Cal (California s Medicaid program), effective as of July 2015, removed many of the initial restrictions to the new generation of HCV direct-acting antivirals (DAAs). These changes include expanding treatment to people with moderate fibrosis, and removing fibrosis restrictions for anyone at high risk for transmitting the virus, including people who actively inject drugs, people living with HIV, women of childbearing age who wish to become pregnant, and men who have sex with men (MSM). Thus, HCV medications can be obtained through existing health coverage mechanisms for the majority of low income individuals living with HCV in California, at no cost to SFDPH. Patient assistance programs have provided an effective means of access for those who are uninsured or underinsured, and the AIDS Drug Assistance Program covers HCV DAAs for its enrollees who do not have other coverage for these medications. Barriers to medication access still remain for many, including some individuals who are privately insured, and individuals who are incarcerated in local jails and state and federal prisons. Nationally, resources devoted to HCV interventions are inadequate to meet HCV-related programming needs: Viral Hepatitis Coordinators receive less than $1 in federal funding for every person living with viral hepatitis in the U.S., 6 and there are still no categorical federal funds for HCV testing. In both California and San Francisco, however, recent advocacy initiatives have resulted in budgetary support for HCV testing and linkage to care services for the first time. End Hep C SF s partnerships among advocates, providers, and funders have the potential to 6 End Hep C SF Strategic Plan

6 continue to make headway in securing adequate support for prevention, testing, linkage, and treatment interventions that will move San Francisco closer to realizing our goal of HCV elimination. Beyond our commitment to obtaining funds to support this work, San Francisco has an incredibly strong foundation upon which we can build this initiative. Our access to HCV prevention, testing, and treatment services is strong compared to much of the U.S., as can be seen in the figure to the right, which highlights the comprehensive services that already exist and are being strengthened through End Hep C SF. This comprehensive base positions us for success for our groundbreaking HCV elimination effort. End Hep C SF believes it is time to commit to eliminating HCV among San Franciscans. It is a daunting task, but it can be achieved with a collaborative, cohesive approach that leverages our many strengths to strategically implement changes that will bring down the incidence and prevalence of HCV in our community. This 3-year strategic plan comes as the End Hep C SF initiative nears its first birthday, marking a year of hard Vision Statement End Hep C SF envisions a San Francisco where hepatitis C is no longer a public health threat, and hepatitis C-related health inequities have been eliminated. Mission Statement To support all San Franciscans living with and at risk for hepatitis C to maximize their health and wellness. We achieve this through prevention, education, testing,treatment, and linkage to reduce incidence, morbidity, and mortality related to hepatitis C. work using a collective impact framework. It is the result of months of discussion and planning by the more than 100 people who participated in End Hep C SF on the Steering Committee or on one or more of our four open-member workgroups. It focuses on the mission, vision, values, and core strategies of End Hep C SF as determined collectively by these participants, as well as the four key initiatives and the strategic priorities that each workgroup determined for this year and for 2018/2019. After decades of existing as an overlooked and severely under-resourced disease, the landscape of HCV is rapidly changing, yielding new opportunities for HCV prevention, testing, and treatment interventions. To remain relevant, this strategic plan will need frequent review and updates as new needs and ideas for intervention develop. 8 End Hep C SF Strategic Plan

7 VALUES We have based our work on our beliefs that: All people living with hepatitis C deserve access to the most effective hepatitis C treatment. Everyone living with or at risk for hepatitis C should have equal access to prevention and care regardless of individual characteristics, including but not limited to race/ethnicity, insurance status, housing status, gender identity, sexual orientation, age, mental health status and substance use. Our work is most effective when people who have lived experience with hepatitis C are involved in all aspects of planning and implementation. It is imperative to draw on the wisdom of service providers, activists, people who use drugs, and others in the community who have been most impacted and most engaged in the fight against hepatitis C over many years. We are committed to working together to: Provide interventions that are evidence based, and continuously review our progress to determine areas where we need to improve, through the regular collection and use of local data related to hepatitis C. End stigma about hepatitis C and people living with hepatitis C. Maximize the health and wellness of people who use drugs by treating them with respect, ensuring access to appropriate services, and empowering them to reduce harm and make choices to improve their health. Continue to invest in populations that have frequently been characterized as difficult to engage, as we realize that these groups often have the greatest unmet need for services and support. COLLECTIVE IMPACT Collective impact occurs when organizations from different sectors agree to solve a specific social problem using a common agenda, aligning their efforts, and using common measures of success. -FSG Consulting* Collective impact involves a group of people getting together to work on a complex issue, under five conditions: 1. Common Agenda: We agree on our vision, mission, values, and strategies. 2. Shared Measurement: We jointly determine shared measures to demonstrate the success of this initiative, for which all the different partners can collect data. 3. Mutually Reinforcing Activities: Instead of acting uniformly, the participants in the initiative strategically coordinate a wide variety of activities that mutually reinforce the common agenda. 4. Continuous Communications: Constant communication exists not only within the Steering Committee and between partners but also with the community. 5. Backbone Support: There is someone/a group identified to hold all the pieces together. For End Hep C SF, this is the Steering Committee with consultant support. * ( 10 End Hep C SF Strategic Plan

8 END HEP C SF COMMUNITY PARTNERS STEERING COMMITTEE To date, 30 community partners have officially signed on to the End Hep C SF initiative. Anyone with lived experience with HCV, people who work on HCV-related issues professionally, and anyone who wants to learn more about HCV are encouraged to sign on as community partners. These partners sign a simple document confirming that they share the vision of HCV elimination in San Francisco, and will offer staff time and expertise to support the work of End Hep C SF. Participation from representatives of these various organizations per the Collective Impact framework is what keeps us steadily moving toward HCV elimination in our city. More information can be found at if your organization would like to officially sign on! End Hep C SF is guided by a Steering Committee comprised of people who have expertise around HCV and share the vision of HCV elimination. Members represent several San Francisco organizations and clinical practices that are on the forefront of HCV testing, linkage, treatment, and advocacy. The Steering Committee meets once a month and makes critical decisions regarding the governance, vision, and cross-cutting activities of End Hep C SF. Steering Committee members also search and apply for funding that keeps our work moving forward. Current members of the Steering Committee include: Katie Burk, MPH (San Francisco Department of Public Health) Kelly Eagen, MD (San Francisco Department of Public Health) Rena Fox, MD (UCSF, San Francisco VA Health Care System) Pauli Gray (San Francisco AIDS Foundation) Theresa Hughes (Hughes Health Care Disparities) Emalie Huriaux, MPH (Project Inform, CalHEP) Isaac Jackson (community member) Annie Luetkemeyer, MD (ZSFG, UCSF) Alfredta Nesbitt (Bayview Hunter's Point Foundation) Kyriell Noon (GLIDE) Robin Roth (San Francisco Hepatitis C Task Force) Mandana Khalili, MD (UCSF) Norah Terrault, MD (UCSF) Rachel McLean, MPH (California Department of Public Health) 12 End Hep C SF Strategic Plan

9 LOCAL DATA, GUIDING ACTION San Francisco is a city of about 865,000 residents. According to the 2015 Current Population Survey (CPS), about 22% of those (almost 194,000) are Baby Boomers (born in ). An estimated 22,500 San Franciscans are people who currently inject drugs. 7 These are two highly impacted and often overlapping groups that comprise a large number of HCV infections in the city. San Francisco also has one of the highest rates of liver cancer in the U.S., driven by both hepatitis B and C; 8 liver cancer is the 9th most common cancer in San Francisco and the 5 th most deadly. 9 While we know that HCV is a major public health concern in San Francisco, until recently limited epidemiological data has inhibited our ability to understand our local epidemic. Laboratory reporting of HCV was not mandated until Now, positive HCV tests must be reported to the local health department; however, negative tests are still not reported, which makes it difficult to calculate how many San Franciscans are actually living with HCV. Some people have never been tested, some were tested before 2007 so were never reported but have not been re-tested (since they already know they have HCV). Some who were originally reported as having HCV may have cleared HCV on their own, or been cured. Still others may have moved outside of San Francisco, or passed away. 10 Despite these data challenges, there are things we DO know. More than 16,000 people with past or present HCV infection have been reported to the SFDPH through mandatory laboratory reporting since More than 2,200 active patients of the San Francisco Health Network (SFHN) in 2015 (3.4% of all patients) were tested and found to be living with HCV. The SFHN includes clinics run by the SFDPH, and does not include clinics that are part of the SF Community Clinic Consortium, which has similar patient demographics. In 2016, out of more than 2100 people tested for HCV through communitybased organizations in San Francisco, 19.2% of those were HCV antibody positive, and more than 130 people were confirmed to be chronically infected. There are almost 1,300 San Franciscans who are known to be co-infected with HIV and HCV (most of these are MSM, which is consistent with the epidemiology of HIV in San Francisco). In all of these cases, the real numbers are likely higher than the numbers of known, reported cases per official registries. 14 End Hep C SF Strategic Plan

10 DISPROPORTIONATE IMPACT OF HEPATITIS C IN SF Using data locally collected about San Franciscans, it becomes clearly evident that there are some groups of people who are infected with HCV at much higher rates than others. Sometimes, these local trends are similar to HCV health disparities seen nationally; however, in some cases our local trends are different from the country overall. This infographic highlights the five groups that are disproportionately impacted by HCV in San Francisco, per local data. It is important to note that there may be additional disparities that are not apparent through currently available local data. incarcerated people 2x people not incarcerated INCARCERATED PEOPLE People who were incarcerated in a San Francisco jail at any point in 2016 were at least twice as likely to be living with HCV than those who were not incarcerated that year. (SFDPH Jail Health Services, unpublished data, 2017) PEOPLE WHO INJECT DRUGS 56% compared to only 2% of the general population AFRICAN AMERICANS 2% In 2012, more than half (55.8%) of the people who recently injected drugs surveyed for the National HIV Behavioral Surveillance survey in San Francisco reported knowing they had HCV. (Coffin, P., et al. Drug and Alcohol Dependence, 2015) HCV positive also HIV positive 46% 61% 27% unaware they had HCV PEOPLE WHO ARE HOMELESS OR MARGINALLY HOUSED Among 246 homeless women surveyed in San Francisco in , 45.9% were HCV antibody positive and 61.1% of those people were also HIV-positive. More than 1 in 4 of those surveyed had never before been tested for HCV, and 27.4% of those testing HCV positive were unaware they had HCV. While this study focused on women, it is important to note that in general, men are twice as likely to be living with HCV in the United States, so it is reasonable to think that rates among homeless men in San Francisco are even higher. (Page, K.M., et al. Poster presentation at The Liver Meeting AASLD, 2016) 6% of people in San Francisco are African American 31% of HCV cases are among African Americans In 2014, 30.8% of HCV cases reported to the SFDPH were among African Americans, despite the fact that African Americans comprise only 6.1% of the San Francisco population overall. (Sanchez, M. HCV Surveillance presentation, Dec 8, 2016) MEN WHO HAVE SEX WITH MEN (MSM) LIVING WITH HIV MSM who are HIV positive MSM who are HIV negative 16% HCV infected 1% HCV infected In 2011, 15.7% of HIV-positive MSM in San Francisco were also infected with HCV, compared to only 1.1% of MSM who were HIV-negative. (Raymond, H.F., et al. Sexually Transmitted Diseases, 2012) 16 TRANS WOMEN compared to only 2% of the general population End Hep C SF Strategic Plan % 2% In the first 19 weeks of the Trans* National Study in San Francisco, 214 trans women were tested for HCV antibodies and 49 (23%) were HCV antibody-positive, indicating a past or present HCV infection. Nine of them did not previously know they were living with HCV. (unpublished data, Trans*National Study, October 6, 2016) BABY BOOMERS 65.9% of the cases of HCV reported to SFDPH between 2007 and 2015 were people born between 1946 and 1964, despite Baby Boomers making up only 22.4% of the population of SF according to the 2015 Current Population Survey. (Nishimura, A. unpublished data, 2017) 22% of people in San Francisco are Baby Boomers 66% of HCV cases are among Baby Boomers 17

11 SUCCESSES OF END HEP C SF TO DATE CORE STRATEGIES In the first year of the End Hep C SF initiative, there have al- Our approach to eliminating HCV in San Francisco involves five core ready been a number of successes thanks to the hard work of the many collaborating partners. strategies: OVERALL SUCCESSES OF THE INITIATIVE 1. Working as a MULTI-SECTOR, COLLECTIVE IMPACT INITIATIVE. The initiative was officially launched in a press conference with SFDPH Director Barbara Garcia on World Hepatitis Day, July 28, 2016 the City Hall was lit up in 2. FOCUSING ON THOSE LIVING WITH HCV AND AT HIGH RISK for transmission, while also acknowledging the importance of HCV EDUCATION FOR THE GENERAL PUBLIC, including providers. 3. Reducing redundancy and leveraging resources wherever possible to MAXIMIZE EFFICIENCY for our work. KEY INITIATIVES To achieve our mission and vision we are focusing on four key initiatives, around which our work groups have been based: yellow and red for HCV, and jade for hepatitis B More than 100 different people attended at least one meeting for End Hep C SF 30 partner agencies signed on to the initiative The San Francisco Cancer Initiative (SF CAN) provided a grant to allow for development of the End Hep C SF website ( and completion of a formal strategic planning and evaluation effort 4. RAISING AWARENESS ABOUT AND REDUCING Pharmaceutical company AbbVie made a charitable do- HEALTH DISPARITIES for people at risk for or living with HCV, especially people who use drugs, African Americans, trans women, Baby Boomers, people living with HIV, people who have been incarcerated, and people who are homeless or marginally housed. 5. SUPPORTING HOUSING ADVOCACY EFFORTS as we understand that housing is healthcare, while simultaneously working to be creative about the need to treat people and prevent HCV in the absence of stable housing. Reducing HCV-related stigma and enhancing HCV education and prevention strategies for populations at highest risk of infection or re-infection Increasing community-based HCV testing and linkage Expanding access to HCV treatment, as well as increasing testing in clinical settings Improving and aligning research and surveillance of HCV citywide and in key populations, to make better use of existing data to guide programs and policies nation to support the Research and Surveillance workgroup to derive a reliable prevalence estimate for HCV in San Francisco, in addition to other infrastructure support for the initiative overall The San Francisco Health Plan announced an award for End Hep C SF for its Innovations and Collaborations for the SF Safety Net Our groundbreaking work was presented at national conferences, including the U.S. Conference on AIDS, the National Harm Reduction Conference, and the National Viral Hepatitis Technical Assistance Meeting The National Association of City and County Health Photo: Larry Wong, courtesy of SF Hep B Free 18 End Hep C SF Strategic Plan

12 Officials (NACCHO) featured an interview about End Hep C SF in its blog series: archives/5705 RESEARCH AND SURVEILLANCE SUCCESSES HCV antibody screening was included in the Trans*National study, which will help us to obtain a reliable estimate of HCV prevalence among trans women in San Francisco, and ensure that as many trans women as possible know their HCV status and are able to enter culturally competent care and treatment leading to cure A leadership meeting was held in October 2016 with more than two dozen of the most well-respected researchers and clinicians in the field of HCV, who worked together to agree upon a process to determine the first-ever estimate of HCV prevalence in the City and County of San Francisco, expected to be released in spring of 2017 Blood Centers of the Pacific shared 10 years of anonymized Got Hep C? Help is right around the corner. HCV testing data on San Francisco blood donors, to contribute to the citywide HCV prevalence estimates The Liver Clinic at Zuckerberg San Francisco General Hospital launched six new HCV treatment studies EDUCATION AND PREVENTION SUCCESSES The OBOT Buprenorphine Induction Clinic (OBIC) prescribed buprenorphine products to 176 patients in 2016 A San Francisco Hepatitis C Summit was held by the San Francisco Hepatitis C Task Force in March of 2016, convening, educating, and energizing 145 stakeholders to move forward toward eliminating HCV in San Francisco The San Francisco Hepatitis C Task Force did outreach and education tabling at 8 community events in 2016, focusing on populations disproportionately affected by HCV Syringe access programs in our city had more than 70,000 contacts, offering San Franciscans safer injection equipment, HCV education, and referrals to services UCSF Alliance Health Project s syringe access program launched. Its first clients benefit from this new service while also receiving additional clinic services including HCV and HIV testing, psychotherapy, and support groups SFDPH staff made more than 20 presentations about HCV basics for San Francisco service providers At least 22 people living with HCV started methadone or buprenorphine with the support of our HCV linkage programs, which is important for HCV prevention because it reduces the frequency of injection among people who use opioids 45 clinicians within the San Francisco Health Network were newly trained to prescribe buprenorphine for people desiring opioid replacement therapy The Family Health Center at Zuckerberg San Francisco General Hospital was awarded a Hearts grant to support patient education classes on HCV A social marketing campaign New Treatments Have Changed the Game launched at Glide, the San Francisco AIDS Foundation, The Opiate Treatment Outpatient Program (OTOP) at Zuckerberg San Francisco General Hospital s Ward 93, the Bayview Hunter s Point Foundation, UCSF Alliance Health Project, and HealthRIGHT360 TESTING AND LINKAGE SUCCESSES The California Department of Public Health awarded funding to the SFDPH for multiple HCV testing and linkage demonstration projects throughout the city The SFDPH funded 3 new HCV linkage programs at the San Francisco AIDS Foundation, HealthRIGHT360, and Glide. These three linkage programs newly 20 End Hep C SF Strategic Plan

13 linked 187 people who had previously been out of care for their HCV to care and treatment More than 2,000 clients tested for HCV antibodies in community-based settings Glide and UCSF Alliance Health Project collaborated to pilot test a mobile HCV testing van in San Francisco UCSF Alliance Health Project continued a collaboration with Homeless Youth Alliance, offering HCV and HIV rapid testing during mobile syringe access hours in the Haight Members of the Testing and Linkage workgroup designed and disseminated an HCV Linkage Checklist, meant for any provider to be able to support a client in linking to care for their HCV care and successfully completing treatment HCV testing programs were implemented at 5 methadone sites in San Francisco UCSF General Medicine systemized HIV and HCV screening, increasing HCV screening by 30% in the first month of the project TREATMENT ACCESS SUCCESSES Jail Health Services initiated a demonstration HCV treatment program in 2016, which includes 3 full-time staff to focus on HCV treatment and coordination for a continuum of care in the community Jail Health Services hired a part-time HCV Linkage Coordinator in 2016, to help increase the number of patients living with HCV who are educated about HCV, treatment, risk of transmission, and HCV services provided in their community; linking patients to other HCV navigators in the community; and assisting those navigators to visit the patients while in custody The San Francisco Health Network launched a new HCV primary care-based treatment initiative, including an ereferral system and in-person trainings for clinicians The San Francisco Health Plan, a citywide managed care plan, treated 730 members for HCV in 2016 Thirteen primary care clinics in the San Francisco Health Network began or continued routinely treating HCV in their patients At least three San Francisco-based methadone programs began offering DOT for their patients living with HCV A shelter-based HCV treatment program was launched at the Next Door and MSC South shelters The Homeless Outreach Team started treating HCV among their patients More than 150 primary care providers in the San Francisco Health Network and HealthRIGHT360 were trained to treat HCV in their patients In 2016, the Positive Health Program at Zuckerberg San Francisco General Hospital (Ward 86) treated over 120 patients (a 60% increase over 2015), with a cure rate of over 99% The Opiate Treatment Outpatient Program (OTOP) at Zuckerberg San Francisco General Hospital s Ward 93 tested 100% of its patients for HCV, and provided treatment to 56 people through directly observed therapy (DOT) at the clinic, more than half of whom have successfully completed treatment to date Doctors in the San Francisco Health Network collaborated with the San Francisco Health Plan to create a pay-for-performance Quality Improvement Measure for HCV treatment in primary care, which incentivizes primary care providers to treat their patients for HCV 22 End Hep C SF Strategic Plan

14 STRATEGIC PRIORITIES The following pages detail each of the strategic priorities for the next three years, as determined by the Steering Committee and individual workgroups within the End Hep C SF initiative. Taken as a whole, the strategic priorities identified here comprise the main bulk of the work that End Hep C SF expects to undertake over the next 3 years; importantly, it is through achievement of these priority items that our members believe we can maximize our progress toward HCV elimination in San Francisco. However, it is also important to note that funding is not yet available to achieve many of these priorities, and significant effort must be made to raise funds to support these activities. In the absence of sufficient funding, members of End Hep C SF are committed to leveraging resources and maximizing the positive impact that our initiative can have on people living with or at risk for HCV in San Francisco, and will continue to adjust these strategic priorities accordingly. 24 End Hep C SF Strategic Plan

15 COMMUNITY-BASED TESTING AND LINKAGE By the end of 2017, double community-based HCV testing to about 4,000 tests per year 2. Secure funding or donations to acquire approximately 2000 more HCV rapid test kits for use in Work to identify funding streams allowing for the urgent hire and training of up to 14 additional staff for HCV testing and navigation in community-based agencies 2018/ Test PWID per year by the end of 2018, plus additional people (especially stimulant smokers and trans women), totaling around 10,000 community-based HCV tests in San Francisco per year overall by the end of Determine the amount of additional funding needed for both HCV test kits and for laboratory confirmation each year given increased testing, then secure funding as needed 3. Create an additional full-time position at SFDPH to support HCV-specific training for counselors and agencies overall 4. Leverage existing HIV testing and navigation staff for increased HCV testing and navigation in community-based agencies, through cross-training and protocol shifts within key agencies 5. Explore ways to develop a more robust volunteer corps to support HCV testing efforts, including by improving the process for counselor training selection to maximize longevity, or increasing the number or capacity of HIV test counselor trainings in San Francisco if needed 6. Implement HCV testing and associated services (including Narcan, HIV testing, and HIV/HCV linkage and navigation support) at Larkin Street Youth Services s youth programs and syringe access in the Haight 7. Implement HCV testing at TRANS:THRIVE, Stonewall, and both TRANS-LIFE and TransLatinas at the San Francisco AIDS Foundation 8. Continue the Glide/UCSF Alliance Health Project mobile van pilot, and work closely with UCSF s Mobilize Against Hep C mobile van study to increase HCV testing 5. Provide supplemental training for all existing, active HIV counselors to provide HCV, with the goal of reaching 100% cross-training of all active counselors by end of Improve the infrastructure at the Lark Inn shelter to allow for HCV and HIV testing on-site 7. Evaluate existing efforts and gaps related to mobile HCV testing services, then plan and launch sustainable van services as appropriate 8. Plan and implement a systematic increase in the number of evening hours for HCV testing citywide 9. Continue to discuss incentives for HCV testing and linkage collaboratively (including with HIV-focused service providers), and jointly determine guidance and best practices for incentives citywide; possibly with a maximum amount that all agree to honor 10. Further promote wide use of the HCV Linkage Checklist developed by the Testing and Linkage workgroup in 2016 by adding as a downloadable tool to the End Hep C SF website 11. Incorporate the HCV Linkage Checklist into agency-specific HCV trainings 12. Incorporate the HCV Linkage Checklist into the HIV/HCV test counselor curriculum 13. Implement a data analysis of HCV testing and positivity to help focus outreach and linkage efforts 14. Explore SFDPH capacity to build a resource guide or wiki related to HCV treatment resources; explore work of others including app called One Degree 15. Promote wider use among HCV providers of the SF HIV Frontline Workers group run by SFDPH for HIV-related providers (sf-hiv-workers@googlegroups.com), and/or create a similar listserv dedicated to HCV providers in San Francisco 14. Improve support resources for challenges with outreach and client engagement and linkage to HCV care and broader support services for PWID and others at high risk for HCV 16. Support the California HIV Alliance and California Hepatitis Alliance s advocacy to secure state general funds for the purpose of providing HIV and HCV testing and linkage to care services in programs serving people who use drugs 26 End Hep C SF Strategic Plan

16 EDUCATION AND PREVENTION / Distribute the Harm Reduction Coalition s pamphlet about HCV prevention for people who use drugs to appropriate agencies/locations 2. Work with the HIV Community Planning Council (HCPC) to develop messaging and educational materials for MSM regarding sexual transmission of HCV 3. Launch a pilot of the intervention developed from the Staying Safe studies, in partnership with the UFO study 4. Complete a literature review around anti-stigma campaigns and provide concrete recommendations for an effective HCV social marketing campaign in this area 4. Develop and launch a large-scale HCV anti-stigma social marketing campaign 5. Translate existing New Treatments Have Changed the Game social marketing materials into Spanish and distribute citywide 6. Widely distribute Know Your Rights stickers, train San Francisco Police Department officers by showing them fit packs with these stickers, and update language in the police bulletin regarding the legality of syringe possession 7. Launch pilot HCV peer education programs at Glide and the UFO study 8. Use the Education and Prevention workgroup to engage at least 5 people outside of SFDPH to conduct at least one provider or client training about HCV; these trainings should include housing providers, shelter staff, community justice courts, mental health facilities, and key staff at the Port of SF and Sheriff s Department 7. Develop protocols for replication and scale-up of the Glide and UFO Study pilot programs for peer-based HCV education 8. Use the Education and Prevention workgroup to engage at least 10 people outside of SFDPH to conduct at least 25 provider or client trainings per year in total; these trainings should include housing providers, shelter staff, community justice courts, mental health facilities, and key staff at the Port of SF and Sheriff s Department 9. Add at least 3 new behavioral health sites to the State Syringe Access Clearinghouse list, to improve access to harm reduction supplies 10. Conduct a needs assessment (a landscape analysis as well as talking to PWID) resulting in concrete recommendations to expand access to opiate replacement therapy (ORT; methadone and buprenorphine) in San Francisco 11. Conduct HCV trainings for staff at 2-4 settings, including Westside, BAART-Market, Fort Help, HealthRIGHT360 s Haight site, and other drug treatment programs 9. Add at least 3 new behavioral health sites per year to the State Syringe Access Clearinghouse list, to improve access to harm reduction supplies 10. Continue to support expanded access to ORT, including any structural interventions proposed as a result of any comprehensive needs assessment conducted 11. Begin regular HCV intervention groups at 3 5 new methadone or substance use settings per year 12. Make a short video for the New Treatments Have Changed the Game campaign, featuring real people who have completed HCV treatment sharing their personal experiences 28 End Hep C SF Strategic Plan

17 RESEARCH AND SURVEILLANCE / Gather clinical data about HCV testing and treatment from large medical providers in San Francisco to inform future research/surveillance about HCV 2. Map clinical data systems in SF to establish a joint dataset (as possible) that will be useful for future re search efforts 3. Use clinical data as a check against other cohort data and available literature to determine a reliable estimate of HCV burden in SF (with both lower and upper plausibility bounds): how many people in SF have ever been identified as having HCV, whether through clinical documentation or self-report? 4. Publish a reliable prevalence estimate and methods used to determine that estimate in a peer-reviewed journal 5. Identify gaps in current data related to HCV prevalence and incidence estimation, and strategize ways to fill those gaps in the future 6. Release a 2-page summary of HCV burden (and limitations in knowledge) for lay people / stakeholders 5. Secure funding as needed to address gaps in current data and improve the quality of prevalence and incidence estimates, including for high-need subpopulations 6. Model the relationship between treatment access and HCV incidence/prevalence in San Francisco. This could lead to prioritization of treatment efforts in San Francisco based on models, and/or predictions of effort/impact in new political climates 7. Set targets for successful HCV elimination: how is elimination defined by End Hep C SF and by when is elimination achievable, given specific parameters? 8. Develop an initial HCV Care Cascade, with the following indicators: Prevalence (all) Spontaneously cleared Tested Antibody positive Confirmed chronically infected Treated Reaching a sustained viral response 12 weeks post-treatment (SVR 12) Re-infected 9. Implement a system for regular updates to the HCV Care Cascade, bi-annually or as the group deems appropriate 10. Develop a report card system for various key players in SF regarding HCV testing and treatment, to incentivize strong performance in these areas 30 End Hep C SF Strategic Plan

18 TREATMENT ACCESS Provide HCV treatment to at least 1400 people in the San Francisco safety net by providing DOT and prescription services at community clinics, methadone and buprenorphine treatment programs, homeless shelters, single residence occupancy hotels (SROs), syringe access programs, and jails 2. Provide resources, training, and education to at least 9 new sites (community clinics, methadone and buprenorphine treatment programs, homeless shelters, SROs, jails, and pharmacies) to begin offering HCV treatment on-site 3. Determine the total number of dedicated nurses at SROs in San Francisco and evaluate best practices for nurse-based treatment at SROs 2018/ Provide HCV treatment to at least 2100 people per year in San Francisco by providing DOT and prescription services at community clinics, methadone and buprenorphine treatment programs, homeless shelters, SROs, and jails. 2. Provide resources, training, and education to at least 18 new sites (community clinics, methadone and buprenorphine treatment programs, homeless shelters, SROs, jails, and pharmacies) to begin offering HCV treatment on-site 3. Plan and deliver trainings for dedicated SRO nurses about HCV DOT, and provide support to begin DOT implementation at their SROs 4. Develop educational materials and support mechanisms for providers regarding HCV treatment, including information about offering DOT and guidance about patients who may be appropriate for other alternative treatment settings, such as pharmacy-based treatment 5. Support the California Hepatitis Alliance s advocacy to ensure the Medi-Cal HCV treatment policy is fully aligned with the clinical guidance provided by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America 6. Support efforts throughout California to protect the provisions of the Patient Protection & Affordable Care Act (ACA), including using the success of End Hep C SF to illustrate to policy makers the critical importance of the provisions of the ACA to people at risk for and living with HCV (including the critical HCV screening, care, and treatment services provided through Covered California, Medi-Cal, and Medicare) 7. Monitor changes to the national health care landscape and making adaptations accordingly whenever possible 8. Discuss strategies for increasing the number or capacity of benefits eligibility workers, particularly located in youth-focused clinics and SFHN clinics with large numbers of patients living with HCV 32 End Hep C SF Strategic Plan

19 CROSS-WORKGROUP PRIORITIES / Hold a large community meeting to announce the initiative to the community, gather feedback from stakeholders, and connect interested community members with ways to be involved in End Hep C SF 2. Ensure an educated workforce at places where people at risk for HCV are served, by providing training to all staff (including reception!) related to HCV 101, engaging people who use drugs, de-escalation techniques, and familiarity with linkages useful to people living with or at risk for HCV; hold at least 6 onsite retreats for large agencies, and offer centralized trainings for others 3. Evaluate the medication locker program being piloted at the San Francisco AIDS Foundation to see whether it is feasible to scale up throughout the city 4. Implement systems to routinely recommend engagement in education and re-infection prevention groups for folks receiving DOT in all settings where offered 5. Begin outreach to HCV treaters to create fast track systems and shorten clinic waiting periods for people being newly linked to HCV treatment, without displacing others with acute health care needs 6. Add a members-only website area to to allow for document storage and sharing 7. Identify at least one individual who will create monthly brief summary updates of initiative progress, for distribution to members and posting on the website for the public (if deemed appropriate) 8. Secure one-time or regular funding to support necessary efforts to treat and prevent HCV, including work group activities and administrative support for the End Hep C SF Initiative overall 9. Stipend peer/secondary exchangers to be network recruiters for testing; look to involve them preliminarily in the testing process and if apporpriate, send them for training. These volunteers can also provide general HCV education, identify people that are clearly treatment-ready, and can sometimes accompany clients to medical visits, etc. 2. Ensure an educated workforce at places where people at risk for HCV are served, by providing training to all staff (including reception!) related to HCV 101, engaging people who use drugs, de-escalation techniques, and familiarity with linkages useful to people living with or at risk for HCV; on an ongoing basis, hold 8-12 on-site retreats for large agencies per year, and offer centralized trainings for others 3. Expand locations for installation of medication lockers (to various agencies, and/or one location per neighborhood, etc.) based on results of the San Francisco AIDS Foundation pilot 4. Explore best practices for incorporating HCV linkage and navigation into DOT programs (currently being explored through the PCORI study) 5. Identify barriers to appointments for rapid treatment initiation in various key treatment sites, so that an action plan can be developed to reduce waiting times for new patients 6. Explore the development of a system for mobile prescribers, who could provide treatment at syringe access sites, SROs, on a mobile treatment van, or other settings as needed 7. Explore San Francisco certification or other process for HCV medication delivery by people who cannot normally prescribe treatment through standard medical licensure 8. Continually assess and recommend new settings and specific agencies that would be good for implementation of DOT in both the Testing and Linkage and Treatment Access workgroups 10. Attempt to obtain donations of necklace/keychain pill holders and distribute as appropriate to support medication storage for people on treatment, especially those who are homeless or marginally housed 11. Continue participating in conversations about benefits of safe consumption services, particularly as they relate to HCV prevention, HCV treatment access, or the improved health of people living with HCV 12. Systematize regular sharing of new research findings or other pertinent clinical updates or information at the start of Education and Prevention as well as Testing and Linkage workgroup meetings, to improve the feedback loop between research and community-based service providers 13. Pilot DOT programs at Martin de Porres and 6th Street Harm Reduction Center 14. Take concrete steps toward realizing a vision that Anywhere needles are available, you can also get a Narcan kit, HIV/HCV testing, and HIV/HCV linkage and navigation support, and all staff will be familiar with HCV education, prevention, and referrals. Steering Committee ICON LEGEND Community-Based Testing & Linkage Education and Prevention Treatment Access 34 End Hep C SF Strategic Plan

20 EVALUATION PLAN KEY STRATEGIC PRIORITIES FOR END HEP C SF AND ASSOCIATED EVALUATION MEASURES Defining and utilizing shared measurement is one of the five main components of the Collective Impact approach. Collecting data and measuring results consistently across all participating organizations not only ensures that all efforts remain aligned, it also enables the participants to hold each other accountable and learn from each other s successes and failures. 11 Unlike many program evaluations which rely on outside evaluators, evaluation of collective impact is embedded within the process of the initiative itself it is the participants themselves who identify key data they need for monitoring their progress participants themselves who collect the data and participants themselves who analyze and use the data regularly for coordinating and strengthening their collective activities. COMMITTEE -STRATEGIC PRIORITIES OVERARCHING/ STEERING COMMITTEE - Build/manage End Hep C SF infrastructure, including funding development and communication systems RESEARCH AND SURVEILLANCE - Determine a reliable estimate of HCV burden in SF - Develop data tools and systems for monitoring progress towards HCV elimination EVALUATION MEASURES - Funding received - Stakeholder participation in workgroups and activities - Public visibility/communications - Data and tools developed and shared (internally and externally) REVIEWING DATA & ADJUSTING ACTIVITIES Groups discuss data and realign their work STRATEGIC PLANNING Groups select priority tasks DEVELOPING SHARED MEASURES Groups identify data needed EDUCATION AND PREVENTION - Develop and distribute HCV educational materials for people who use drugs (PWUD) and MSM - Increase capacity of organizations serving PWUD and MSM through provider trainings about HCV - Number of educational materials distributed - Number/type of trainings provided - Pre/post assessment of organizational practices related to HCV care - Reported number of tests conducted at community-based sites COLLECTING DATA Individual organizations collect data and report to groups COMMUNITY-BASED TESTING AND LINKAGE - Expand access to HCV testing in SF, increasing number of community-based HCV tests to 10,000/year by Number of HCV testers trained - Number of new locations offering HCV testing - Proportion of community-based sites offering HIV/HCV co-testing Participants in the Steering Committee and the four topic-specific workgroups identified what data was needed to monitor their progress, how data would be collected, who would collect the data, and how frequently data needed to be analyzed and reviewed. In the pictorial on the next page, each group s main strategic priorities are linked to primary data/measurement needed to understand their progress and impact. TREATMENT ACCESS - Expand access to HCV treatment in SF, increasing number of people treated in SF safety net sites to 2100/year by Number of provider trainings conducted - Number of people treated in safety net sites - Number of new locations offering HCV treatment - Reinfection rates, by site and overall 36 End Hep C SF Strategic Plan

21 References 1. Ly KN, Hughes EM, Jiles RB, Holmberg SD. Rising mortality associated with hepatitis C virus in the United States, Clinical Infectious Diseases. 2016; 62(10): Major B, O Brien LT. The social psychology of stigma. Annual Review of Psychology. 2005; 56: National Academies of Sciences E, and Medicine,. Eliminating the public health problem of hepatitis B and C in the United States: Phase one report. Washington, DC: The National Academies Press; United Nations, General Assembly. Resolution adopted by the General Assembly on 25 September New York, NY: United Nations; World Health Organization. Combating Hepatitis B and C to Reach Elimination by Geneva: Switzerland, May McCloskey E. Is $1 enough for viral hepatitis prevention? NASTAD Blog. Vol Washington, DC: National Association of State and Territorial AIDS Directors (NASTAD); End Hep C SF thanks the SF-CAN initiative and AbbVie for their generous support of the development of this strategic plan and other activities crucial to the success of our elimination initiative 7. Chen YH, McFarland W, Raymond HF. Estimated Number of People Who Inject Drugs in San Francisco, 2005, 2009, and AIDS and behavior. 2016; 20(12): National Cancer Institute. State Cancer Profiles: Incidence Rate Report of Liver & Bile Duct Cancer, , for United States by County. 9. San Francisco Cancer Initiative (SF CAN). Liver Cancer. 2016; Available at : Communicable Disease Control and Prevention Section. Chronic Hepatitis B and Hepatitis C Infection Surveillance Report, 2010, San Francisco, California. San Francisco: San Francisco Department of Public Health; From Collaboration for Impact. Developing Shared Measures. Available at: Accessed Get Involved To get involved in End Hep C SF, visit and click on get involved. You are also encouraged to join any of our workgroups, which are open to the public. We welcome anyone with lived experience with HCV, people who work on HCV-related issues professionally, and anyone who wants to learn more about HCV. More information is available on our website at 38 End Hep C SF Strategic Plan

22 This strategic plan was written for End Hep C SF with thanks to the staff, researchers, patients, patient advocates, and clinicians who have dedicated countless hours to preventing and treating hepatitis C in San Francisco. Elimination is finally within reach! 2017 Cover Photo: Larry Wong, courtesy of SF Hep B Free LAYOUT & DESIGN: JillianBanks-Kong.com